Writing a letter with a Mental Health Counselor

***Replace all Green Font with your details***

providers for ICATHInformed Consent for Access to Trans Health Care

DATE

PROVIDER NAME
ADDRESS
ADDRESS
PHONE/FAX

Dear PROVIDER NAME:

NAME has met with a therapist/advocate regarding hormone use.

PRONOUN has discussed the following in regards to beginning hormone use:

  • Potential social consequences

  • Potential occupational consequences

  • Potential effects on familial relationships

  • Potential financial costs

  • Potential impacts on mental and physical health

NAME is informed on the psychosocial impacts of hormone use and is able to make an informed decision.

Sincerely,

NAME, CREDENTIAL
Therapist/Advocate

I, NAME, have explored the potential psychosocial impacts of hormone use and am able to make an informed decision.

Sincerely,

NAME                                               NAME
Patient                                             Parent/Guardian

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